Healthcare Provider Details

I. General information

NPI: 1114264462
Provider Name (Legal Business Name): JEFFREY J. RYAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MAPLE RD
JOLIET IL
60432-1439
US

IV. Provider business mailing address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-1100
  • Fax:
Mailing address:
  • Phone: 815-300-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.010063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: